LIVER CANDIDATE SUMMARY



Ohio Medicaid Required Information Form**PLEASE NOTE**This form is only required when Ohio Medicaid is the PRIMARY insurer. The following information is required by Ohio Medicaid for patients seeking prior authorization for extra renal transplant. All information indicated below is required. Ohio Medicaid will not issue a prior authorization without this required information. This form must be submitted to the OSOTC as a Word document. It may be uploaded to the online review system along with the clinical summary at time of review –OR– it may be emailed to: review@Hospital/Billing Provider InformationHospital Name: FORMTEXT ?????NPI Number: FORMTEXT ?????Address: FORMTEXT ?????Contact Person: FORMTEXT ?????Contact’s Number: FORMTEXT ?????Transplant Information(Beginning and Ending Dates of Services MUST be provided in instances where the surgery date is known)Organ:ICD 10 CodeICD 10 Desciption FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Surgery Date (if known): FORMTEXT ?????Begin Date of Service: FORMTEXT ?????End Date of Service: FORMTEXT ?????Recipient InformationPatient Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Address:(full residential address) FORMTEXT ?????Social Security #: FORMTEXT ?????Ohio Medicaid #MUST be the 12-digit billing#) FORMTEXT ?????Procedure Codes & Descriptions InstructionsProcedure code(s) and description(s) must be selected from the table shown on page 2 of this form.Only one “Code & Description” should be selected per organ to be transplanted. When multiple organs are to be transplanted, you may select multiple codes if a combination code does not already exist.Copy your selection from the table on page two of this form and paste it into the “Procedure Codes & Descriptions” area in the table above. ICD 10 Procedure Codes & DescriptionsOrgansCodeDescriptionHeart02YA0Z0Transplantation of Heart, Allogeneic, Open ApproachLung Bilateral0BYM0Z0Transplantation of Bilateral Lungs, Allogeneic, Open ApproachLung Left0BYL0Z0Transplantation of Left Lung, Allogeneic, Open ApproachLung Left0BYG0Z0Transplantation of Left Upper Lung Lobe, Allogeneic, Open ApproachLung Left0BYH0Z0Transplantation of Lung Lingula, Allogeneic, Open ApproachLung Left0BYJ0Z0Transplantation of Left Lower Lung Lobe, Allogeneic, Open ApproachLung Right0BYK0Z0Transplantation of Right Lung, Allogeneic, Open ApproachLung Right0BYC0Z0Transplantation of Right Upper Lung Lobe, Allogeneic, Open ApproachLung Right0BYD0Z0Transplantation of Right Middle Lung Lobe, Allogeneic, Open ApproachLung Right0BYF0Z0Transplantation of Right Lower Lung Lobe, Allogeneic, Open ApproachLiver0FY00Z0Transplantation of Liver, Allogeneic, Open ApproachPancreas0FYG0Z0Transplantation of Pancreas, Allogeneic, Open ApproachIntestine Large0DYE0Z0Transplantation of Large Intestine, Allogeneic, Open ApproachIntestine Small0DY80Z0Transplantation of Small Intestine, Allogeneic, Open ApproachStomach0DY60Z0Transplantation of Stomach, Allogeneic, Open Approach ................
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